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Heart Failure Supportive Care in 2016 GIL KIMEL MD, MSC, FRCPC Dept. of Medicine Division of Palliative Care Disclosures Objectives Concept of Palliative Care Heart Failure Supportive Care Heart Failure Supportive Care Clinic (HFS) Palliative Medicine Palliative – Palliare (Latin) – to cloak Approach to improve QoL of pts. and families facing life- threating illness Physical, psychosocial, spiritual Palliative Medicine “What has surprised me is how little palliative care has to do with death. The death part is almost irrelevant. Our focus isn’t on dying. Our focus is on quality of life” Dr. Balfour Mount McGill University Case 80 female presenting to ED with SOB PmHX: CHF – NYHA III, DM, 25 PY smoker 3 yrs ago… large anterior wall MI In last 2 years: 7 admissions to CTU decompensated HF Poorly compliant with diet, fluid and exercise Case History: Symptoms: SOB at rest (NYHA IV) Exercise tolerance – 5 feet; + orthopnea/PND; no CP; poor sleep ; ESAS >65 Compliance: Poor fluids /salt restriction Medication: ASA, ACEi, BB, Statin, Lasix, Aldactone, Warfarin, Insulin, Allopurinol Exam: BP 84/60, HR 88, O2 Sats 92% (6 L HF), T: 36.9 JVP Angle of Jaw, Crackles throughout, peripheral edema, ascites, S1, S2 normal, cool extremities Heart Failure Inability of heart to meet metabolic demands of body Jessup , NEJM 2003 Heart Failure - Reality Impacts QoL and length of life High health care costs ~ $2 billion/ year in Canada 25,000 deaths / year in Canada QoL in NYHA III/IV … ‘trade’ ½ of remaining life to feel better Krum 2009, Lewis 2001 Heart Failure Only cardiac syndrome rising in prevalence Survival rate for HF ≈ Malignancy : 1 yr = 66% 2 yr = 50% 5 yr = 35% Compared to malignancy : Less palliative care Less likely to understand their illness Less likely to plan for death More likely to die in hospital Johnson Postgrad Med 2007; Yeung CMAJ 2012 Heart Failure Medication decreases morbidity and mortality ACE-I, ββ, spironolactone Treatments are palliative PCI, TAVI, LVAD Heart Failure Patients often have symptoms early Symptoms affect daily activities, work, relationships 2005 ACC / AHA: class 1 recommendations for inclusion of Palliative Medicine in heart failure treatment Heart Failure NYHA Functional Class: Mortality 1 yr Class I –Without symptoms Class II – Symptoms ordinary activity Class III – Symptoms < ordinary activity Class IV – Symptoms at rest 5-10% 15-30% 15-30% 50-60% Taylor 2003 Heart Failure – Palliative Care Only ~ 10-15% of pts with HF receive palliative care Evidence for Palliative Care in HF less than for Cancer CHF differences from Cancer: Prognostication more difficult Thought to be more benign Pt feels unwell told “doing well” Feel better on treatment Murray BMJ 2002; O’Brien BMJ 1998, Goldstein 2012 HF Symptom Prevalence SOB 60-88% Confusion 18-32% Fatigue 69% Constipation 38-42% Nausea 48% Edema 44% Depression 9-36% Dizziness 21% Insomnia 36-48% Pain 41-77% Anxiety 49% JP Solano 2006 Characterize survival on HF admissions BC cohort >14,000 patients Survival time measured after first and each hospitalization Number of CHF hospitalization = strong predictor of mortality Setoguchi AHJ 2007 Survival Decreases with Repeated Hospitalizations Setoguchi AHJ 2007 Phases of HF Goodlin JACC. 2009;54:386-396 Trajectories at End-of-Life Jaarsma presentation; British Medical Journal 2008 Transition to Palliative Care Murray 2007 ? Better Model Concurrent Care N I Y I H I A Standard Heart Failure Treatment C L A S S Palliative Care Did I tell patient what’s coming? http://palliative.info/pages/TeachingMaterial.htm Back to Case Improve patient comfort IV Lasix, immediate opioids, possibly oxygen Communicate with patient and family Discuss options and prognosis Make recommendations ? 2 options: Admit to CCU or Medicine and try aggressive diuresis Heart Failure Supportive Care Clinic (HFS) Established in January 2011 at St. Paul’s Hospital / VGH Pilot Project - Hypothesis Heart Failure Supportive Care Clinic (HFS) Clinic Concept Dr. Temel’s Study NEJM Newly diagnosed metastatic NSCLC (n =151) Randomized to: Early palliative care & standard oncology care Standard oncology care Primary outcome: QoL and Mood at 12 weeks QoL measured by FACT – L Mood measured by Hospital Anxiety and Depression Scale Temel, NEJM, 2010 Quality of Life Mood Temel, NEJM, 2010 Temel, NEJM, 2010 Heart Failure Supportive Care Clinic (HFS) Combines specialties of cardiology and palliative care Out-patients Patients referred by cardiologists Patients not usually candidates for transplant or LVAD All patients are very complex medical patients Advanced Heart Failure – NYHA III or IV All have multisystem disease ALL have moderate to severe symptoms Based on ESAS Heart Failure Supportive Care Clinic (HFS) Goal of Clinic: Assess and treat: SOB, Fatigue, Constipation, Anxiety, Insomnia Polypharmacy ICD deactivation Advance Care Planning BC Palliative Care Benefits & Home DNR Hospice To help patient understand complex trajectory Results: ESAS Scores Compared first ESAS score to most recent 64% improved 13% stable Mean improvement: 5.1 points SOB & overall well-being most improved Results: Medications Average medications at first visit: ~10 16 patients had medication reduction without symptoms Commonly discontinued meds: Atorvastatin Simvastatin Zopliclone Amlodipine Conclusions First study to evaluate HeF Clinic Data shows that it has a positive impact on several quality of life measures Results consistent with known high mortality of CHF 10 out-patient NYHA III/IV RCT 4 days of 5mg of morphine vs. placebo Results: 6/10 patients reported decreased SOB On Morphine: Breathlessness score fell Sedation not significant by day 4 No significant differences in other measure (nausea, BP, HR) ICD – Implantable Cardioverter Defibrillator ICD Deactivation Poor Communication on ICD deactivation > 95% of hospices admit pts with active ICDs > 50% of hospices have had pts shocked ~ 42% of pts have shocking function deactivated 73% no discussion of turning off ICDs Goldstein 2004, 2010 ICD Deactivation Physicians uneasy talking about ICD deactivation Patients don’t want to talk about it either Physicians should advocate for patient Lampert 2010 ICD Deactivation Last weeks of life: 20% receive shocks Title: Palliative Care on the Heart Failure Team: Mapping Patient and Provider Experiences and Expectations Multicenter: Western, Dalhousie, UBC Data collection –completed Objectives Factors that influence palliative care integration Systems of communication Identify opportunities for improved integration of palliative care Thank you UBC Cardiology Team - Dr. Andy Ignaszewski Nursing team – Annemarie, Ella, Cindy, Dianne, Erin, Linda Frances Simpson & Tom Hahn Email: [email protected] Suggestions for CHF Meds Opioids: Depending on severity of Dyspnea, pain, and age Requires frequent reassessment Hydromorphone: 1Mg SC q 4 hr regular Hydromorphone: 1Mg SC q 1 hr PRN for dyspnea Recalculate q4 hr dose every 1-2 days Based on previous 24 hr useage Midazolam: 1-2 Mg SC q 2 hrs PRN for worsening SOB Nozinan: 2.5 – 5 Mg SC q 3 hrs PRN for agitation